AJR 2000; 175:119-120
© American Roentgen Ray Society
Colonic Stent Placement Facilitated by Percutaneous Cecostomy and Antegrade Enema
T. E. Velling1,
L. D. Hall and
F. J. Brennan
1
All authors: Department of Radiology, Naval Medical Center San Diego, 34800
Bob Wilson Dr., San Diego, CA 92134-5000.
Received November 5, 1999;
accepted after revision December 15, 1999.
The views expressed in this article are those of the authors and do not
reflect the official policy or position of the Department of the Navy,
Department of Defence, or the United States government.
Address correspondence to T. E. Velling.
Introduction
Since Tejero et al. [1]
first described the procedure in 1994, colonic stenting has gained acceptance
both as a means of decompressing the colon before surgery to remove
obstructing lesions, and for palliation in nonsurgical candidates. Stenting is
performed with radiologic and endoscopic guidance from a retrograde approach.
To the best of our knowledge, crossing colonic obstructions from an antegrade
approach via percutaneous cecal access has not been described in the
literature.
Subject and Methods
A 58-year-old woman with metastatic ovarian carcinoma, including diffuse
peritoneal metastases, presented with clinical signs of acute colonic
obstruction. An acute abdominal series revealed severe colonic dilatation and
an air—fluid level in the distal descending colon.
She was initially referred by the gynecology—oncology service for
placement of a percutaneous cecostomy tube because she was a poor surgical
candidate. We offered the possibility of colonic stent placement for
palliation, and if unsuccessful, cecostomy placement. After informed consent,
a Gastrografin (Bracco Diagnostics, Princeton, NJ) enema was performed with
the patient in the left lateral decubitus position. Conscious sedation was
provided with IV midazolam (Versed; Roche Laboratories, Nutley, NJ) and
fentanyl (Sublimaze; Elkins-Sinn, Cherry Hill, NJ). The enema showed complete
obstruction at the rectosigmoid junction
(Fig. 1A). With fluoroscopic
guidance, we initially attempted to cross the lesion with multiple catheter
and guidewire combinations but were unsuccessful. The gastroenterology service
at our institution then attempted to cross the lesion with endoscopic guidance
but was also unsuccessful.
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Fig. 1A. —58-year-old woman with metastatic ovarian carcinoma and acute
colonic obstruction. Digital radiograph obtained after Gastrografin (Bracco
Diagnostics, Princeton, NJ) enema shows complete obstruction (arrow)
at rectosigmoid junction.
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Next, to decompress the colon, a 24-French Malecot cecostomy catheter was
placed percutaneously with fluoroscopic guidance. The patient's colon became
much less distended and she was discharged 3 days later.
She returned the following week with stool leakage around the cecostomy
tube. Because the patient stated she was occasionally passing flatus, we
decided to make another attempt at crossing the lesion using an antegrade
approach. A 5-French vertebral catheter was manipulated through the cecostomy
tube and, with the use of a.035-inch Glidewire (Terumo; Boston Scientific,
Watertown, MA), was advanced to the distal descending colon. An antegrade
Gastrografin enema showed a long segment of severe stricture of the sigmoid
colon. The lesion was crossed and the wire coiled in the rectum
(Fig. 1B). The wire was
manually pulled out of the rectum for through-and-through wire access, and
after advancing the catheter, we exchanged the wire for a 260-cm,.038-inch
Amplatz wire (Boston Scientific).
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Fig. 1B. —58-year-old woman with metastatic ovarian carcinoma and acute
colonic obstruction. Digital radiograph from antegrade enema through cecostomy
shows wire crossing known stricture in antegrade direction, coiled in
rectum.
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A 24 x 70 mm uncovered Wallstent (Boston Scientific) was then
positioned across the lesion and deployed
(Fig. 1C). The central portion
of the stent was narrow, so a second 24 x 45 mm Wallstent was deployed
in this portion to provide more radial force. The stricture was gently dilated
with an 18-mm XXL balloon (Boston Scientific). A third 24 x 70 mm
Wallstent was deployed above the initial stent to provide a smoother
transition with the descending colon (Fig.
1D). The patient began having bowel movements, and the following
day, the cecostomy tube was exchanged for a 24-French gastrostomy button
(Mic-Key; Ballard Medical Products, Draper, UT) to seal the cecostomy
tract.
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Fig. 1C. —58-year-old woman with metastatic ovarian carcinoma and acute
colonic obstruction. Digital radiograph shows proximal and distal extent of
malignant stricture (arrowheads). Note stent delivery sheath
(arrow) that was advanced across stricture before deployment.
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Results
Although some stool leakage occurred around the gastrostomy button, the
patient was discharged. She carried an ostomy bag over the gastrostomy button
and could have bowel movements. The stents remained patent, providing good
palliation until the patient's death several weeks later.
Discussion
The approach to acute colonic obstruction has traditionally been staged
surgery consisting of colostomy, tumor resection, and colostomy take-down.
More recently, colonic stent placement has been used as the initial treatment
of acute colonic obstructions, allowing bowel preparation and one-stage
surgery with end-to-end anastomosis in surgical candidates. Stent placement
has also been used as palliation in nonsurgical candidates
[2,3,4,5,6,7].
Complications may include colonic perforation in 5-15% of patients
[5,7]
and stent migration in 29% of patients
[8]. Stent patency rates in
patients treated for palliation vary but averaged 17 weeks in one series
[9].
The technique involves a water soluble—contrast enema and
fluoroscopic or endoscopic guidance to cross the lesion in a retrograde
manner. After measuring the length of the lesion, appropriately sized flexible
self-expanding metallic stents are deployed across the lesion
[10].
Although the technical success rates for the procedure are high, a 3-10%
failure rate occurs, with inability to cross the obstructing lesion retrograde
[2,3,7].
To our knowledge, ours is the first reported case of successful antegrade
colonic stent placement. Given our patient's nonsurgical status and our
inability to cross the lesion retrograde, the only other alternative for
colonic decompression was percutaneous cecostomy. Fortunately, we could use
this access to negotiate a wire-and-catheter system through the colon and
across the lesion. The cecostomy tract was then sealed with the gastrostomy
button. This solution simplified nursing care and was much more acceptable to
the patient and her family than a large percutaneous cecostomy catheter.
In conclusion, although technical failures in retrograde placement of
colonic stents are rare, antegrade placement via percutaneous cecostomy access
is technically feasible in patients with favorable colonic anatomy. This
procedure may provide an alternative means of colonic decompression in cases
in which percutaneous cecostomy fails to provide acceptable palliation in
nonsurgical candidates.
References
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Introduction
Subject and Methods
